Role of the National Health Service Corps in Delivering Substance Use Disorder Treatment in Underserved Communities

The National Health Service Corps (NHSC) Loan Repayment Program (LRP) offers primary care, dental, and behavioral health care providers the opportunity to reduce debt accrued from loans that were used to earn a degree in their health profession. In exchange, LRP participants provide health care at NHSC-approved sites, which are health care facilities in underserved communities with limited access to care. Recruitment of clinicians with opportunities to participate in loan forgiveness programs is one evidence-based pathway to improving provider retention in rural and underserved areas (1–4).

In September 2018, the Health Resources and Services Administration (HRSA) received funding from the U.S. Department of Health and Human Services to combat the opioid crisis. HRSA’s Bureau of Health Workforce used this funding to launch a multipart strategy aimed at increasing the workforce capacity of the U.S. health care system to prevent and treat opioid use disorder. One part of this strategy included increasing the number of clinicians delivering medications for opioid use disorder and substance use disorder by retaining and increasing the number of clinicians in the NHSC who are trained to provide medications for these disorders. To help achieve this goal, HRSA expanded the LRP in fiscal year (FY) 2019 to include two new LRPs: the Substance Use Disorder LRP and the Rural Community LRP. Clinicians in both new programs agree to serve 3 years at an NHSC-approved substance use disorder treatment site located in a mental health or primary care health professional shortage area and can receive higher loan repayment awards—$75,000 in the Substance Use Disorder LRP and $100,000 in the Rural Community LRP—compared with the standard LRP, which requires a 2-year commitment and will repay up to $50,000 in loans.

In this study, we provide a summary of the dual challenges of the opioid epidemic and the COVID-19 pandemic, particularly among vulnerable populations, and describe the expansion of the NHSC clinician workforce in underserved areas. We then summarize key findings about the expansion of substance use disorder services at NHSC sites after the loan repayment expansion and describe some of the impacts of the COVID-19 pandemic on NHSC clinician service delivery.

The Opioid Epidemic

Opioid use disorder is a leading public health concern in the United States, with serious health, social, and economic consequences. In 2019, an estimated 1.6 million persons ages 12 years or older had an opioid use disorder in the past year, a decrease from 2.0 million in 2018 (5). However, despite increased access to treatment and availability of naloxone, opioid overdose deaths increased from 2018 to 2019 by approximately 5%. Synthetic opioids (e.g., fentanyl) are a primary driver of opioid overdoses, and deaths involving synthetic opioids increased by 1,040% from 2013 to 2019 and accounted for 52% of all drug overdose deaths in 2019 (6). Opioid overdose affects communities of all demographic backgrounds, although the recent surge in overdose deaths driven by synthetic opioids has disproportionately affected Black and Hispanic populations (7, 8). Despite the growing public health concern and lethal consequences, only 18% of persons with opioid use disorder reported receiving medication for treatment in 2019 (9).

Drug overdose death rates in urban areas have historically been higher than in rural areas, although rural rates began rapidly increasing in 2004 and first surpassed urban rates in 2015 (9, 10). Substance use disorder is particularly problematic and pervasive in rural communities, where the need for high-quality, accessible, and affordable prevention, treatment, and recovery services often outpaces the resources required to make them available. Because of the lack of access to behavioral health services in many rural communities, patients must travel long distances to receive care (11). Sixty percent of areas with shortages of mental health professionals are rural or partially rural (12). This lack of access to care contributes to worse health outcomes and disproportionate rates of preventable deaths of patients in rural versus nonrural areas (13, 14).

The COVID-19 Public Health Emergency

The COVID-19 pandemic has exacerbated the multifaceted issues of the opioid epidemic. Reports from all 50 U.S. states (15) and provisional data from the Centers for Disease Control and Prevention (CDC) (16, 17) have shown that opioid overdose death rates spiked during the pandemic. Barriers in access to social support and treatment hampered efforts to address opioid use disorder across the nation. In response to public health guidance for preventing community-related COVID-19 exposures, treatment programs, harm reduction organizations, and other health care providers who serve patients with substance use disorders reduced service hours (14). Face-to-face interaction with service providers is considered important for recovery for many patients with a substance use disorder; thus, despite advances in telehealth and virtual visits, patients had limited access to peer support groups and other forms of social support (18–20). Emergency departments (EDs) are another source of stabilizing care for many individuals with substance use disorder and opioid use disorder and can be an entry point into treatment, but the influx of COVID-19 cases overwhelmed EDs and the health care system as a whole, further limiting access to care.

COVID-19 also intensified burnout among health care professionals, which has been a growing concern in the field, particularly in the mental health workforce (21). In addition to exacerbating burnout among clinicians, the COVID-19 pandemic disproportionately affected people of color and people with low socioeconomic status, who are more likely to live in underserved areas. These populations, particularly Black, Hispanic, and Indigenous people, had a higher risk for COVID-19 mortality and experienced the highest rates of COVID-19 infection, hospitalization, and death (22).

Role of NHSC LRPs in Increasing the Number of Providers in Underserved Areas

Challenges compounded by the COVID-19 pandemic have strained the capacity of behavioral health providers and the health care system to treat opioid use disorder, other substance use disorders, and related mental health problems. Several federal policy changes, such as legislation that expanded the types of providers eligible to prescribe buprenorphine, were enacted to expand access to treatment for opioid use disorder before the COVID-19 public health emergency; however, there remains a shortage of providers with the capacity and willingness to prescribe buprenorphine, and disparities have persisted, particularly in rural areas (23–25). As of 2018, nearly two-thirds of U.S. counties had at least one provider, but 80% of small and remote counties (counties whose largest town has fewer than 10,000 residents, regardless of proximity to larger counties) lacked a provider (26). Even when providers are available to prescribe medications for opioid use disorder, other barriers, such as perceived lack of patients’ ability to pay, stigma related to such medications, or lack of complementary counseling support systems, can reduce providers’ willingness to prescribe. The research community has been voicing concerns regarding the impact of workforce shortages on substance use disorder treatment and proposing a range of approaches to policy makers (25, 27–29). In this article, we provide more insight into the role of the NHSC and LRP expansion in providing care in underserved communities.

Methods

We used administrative data from HRSA, survey findings, and key informant interviews with NHSC clinicians and site administrators to describe the impacts of the NHSC programs and COVID-19 on service delivery. We examined the composition of all NHSC clinicians serving in FY 2020 at HRSA health centers (Federally Qualified Health Centers and look-alikes) because 60% of NHSC clinicians serve at such health centers. These facilities are located in medically underserved areas and provide services to patients regardless of their ability to pay (30). To characterize the communities served by clinicians in the NHSC LRP expansion in FY 2019, we used public data from several sources, including the CDC and the Agency for Toxic Substances and Disease Registry (ATSDR) (31), the National Institute of Environmental Health Sciences (32), the University of Wisconsin Population Health Institute (33), the U.S. Census Bureau and the Small Area Income and Poverty Estimates (SAIPE) program (34), and the U.S. Department of Agriculture (USDA) Economic Research Service (ERS) (35).

We administered a Web-based survey to all FY 2019 NHSC clinicians (N=4,012) and administrators at active NHSC sites (N=3,707). We obtained approval from the NORC at the University of Chicago Institutional Review Board on November 4, 2019. The surveys were pilot-tested and reviewed by survey methodologists and subject matter experts and were administered to clinicians from September 16, 2020, to November 23, 2020, and to site administrators from October 1, 2020, to January 4, 2021. The response rates were 67% (N=2,688 of 4,012) for the NHSC clinician survey and 54% (N=2,017 of 3,707) for the NHSC site survey. We also conducted key informant interviews with nine NHSC site administrators and nine NHSC clinicians from April 1, 2021, to June 30, 2021, to understand how COVID-19 affected NHSC clinicians’ and sites’ service delivery for substance use disorder. The interviews explored changes in health workforce shortages, substance use disorder treatment delivery (e.g., shifting to telehealth), patient treatment needs, facility resource needs, and recommendations to prepare for future public health emergencies and natural disasters. We purposively sampled sites and clinicians to obtain a mix of HRSA geographic locations, facility types, and clinician disciplines.

We linked county-level data sets (from the public sources listed above) to NHSC sites that had clinicians to understand the social and pandemic-related vulnerabilities and sociodemographic characteristics of communities that NHSC clinicians served. These data sets included the Social Vulnerability Index (SVI) from the CDC and ATSDR, the COVID-19 Pandemic Vulnerability Index (PVI) from the National Institute of Environmental Health Sciences, data on majority-minority counties from the University of Wisconsin Population Health Institute County Health Rankings, data on persistent poverty from the U.S. Census Bureau and the SAIPE program, and data on rural-urban commuting area (RUCA) codes from the USDA ERS.

For the SVI and PVI, we classified counties as having high vulnerability if their index score was in the highest 20% (indicating the most vulnerable). The majority-minority variable is a binary indicator concerning whether more than half of a county’s population was from a social, ethnic, or racial minority group. Persistent poverty is a binary indicator of whether 20% or more of a county’s population were living in poverty as measured by the 1990 and 2000 U.S. Censuses and the 2018 SAIPE program poverty rate.

We used RUCA codes to examine the presence of NHSC clinicians in rural areas at a more granular level than a binary urban-rural or metropolitan-nonmetropolitan classification. RUCA codes use multilevel county classifications that measure population density, urbanization, and daily commuting to create 10 designations. In this analysis, we examined micropolitan areas (RUCA codes 4–6), small towns (RUCA codes 7–9), and the most sparsely populated rural areas (i.e., those with fewer than 2,500 residents) (RUCA code 10).

Results

Changes in NHSC Clinician Service Delivery

To illustrate the proportion of all NHSC clinicians at HRSA health centers, Table 1 shows the total number of NHSC clinicians serving in FY 2020 (October 1, 2019, to September 30, 2020) relative to the total national staff at HRSA health centers. Approximately 24% of nurse practitioners and physician assistants at HRSA health centers were NHSC clinicians, whereas 7% of physicians were NHSC clinicians. Just over one-quarter (26%) of licensed clinical psychologist full-time equivalents (FTEs) were NHSC clinicians, as were 15% of other (e.g., licensed professional counselors, marriage and family therapists) licensed mental health care providers and 6% of psychiatrists.

We then examined the communities where the first cohort of participants in the LRP expansion serve (new FY 2019 NHSC clinicians in the LRP) compared with the characteristics of the average U.S. county. As shown in Table 2, the new LRP participants served in counties where a higher proportion of the population had high social vulnerability and where the population was more diverse, compared with the national average.

Figure 1 shows a map of the national distribution of the new FY 2019 LRP participants and counties with the highest levels of social vulnerability (which refers to the potential negative effects on communities caused by external stresses on human health).

Over time, the total number of NHSC clinicians in rural areas has grown (Table 3). The total number of NHSC clinicians working in all rural areas increased by 59% between FY 2017 and FY 2020. In the same period, the proportion of NHSC clinicians working in small towns (RUCA codes 7–9) increased by 62%, from 779 in 2017 to 1,264 in 2020. After the LRP expansion in FY 2019, the placement of clinicians in rural areas has accelerated, demonstrated by the larger change in the number of clinicians from FY 2018 to FY 2020 (a 48% increase) compared with the growth from FY 2017 to FY 2018 (a 7% increase). This finding reinforces the important role the NHSC has in expanding access to care for underserved counties.

Findings from our FY 2019 NHSC site survey showed that 42% (N=851 of 2,017) of all NHSC sites reported having expanded or added two or more behavioral health services since the September 2018 funding increase. Table 4 shows the specific health services that sites added or expanded, including medications for opioid use disorder (62% of sites); other opioid use disorder treatment (44%); and substance use disorder treatment, excluding opioid use disorder treatment (42%). Sites also increased screening and assessment for behavioral health disorders (37%).

Impact of COVID-19 on Substance Use Disorder and Opioid Use Disorder Treatment at NHSC Sites

At the time of the survey (fall 2020), 22% (N=186 of 865) of sites that reported a change in their delivery of behavioral health services experienced a reduction in their ability to provide services for substance use disorder, and 12% (N=102 of 865) reported a reduction in their ability to provide medication for opioid use disorder services due to the COVID-19 pandemic. These reductions can be attributed partly to the financial strains and workforce shortages that increased because of the pandemic (36). However, 71% (N=616 of 865) of NHSC sites provided more services for substance use disorder via telehealth during this time, despite many sites facing workforce changes or reductions. Among NHSC sites that were designated as substance use disorder service providers, 86% (N=325 of 379) increased the use of telehealth services for substance use disorder treatment. NHSC sites, however, also reported numerous challenges with increasing the use of telehealth. Technical difficulties, such as issues with Internet access and devices for teleconferencing, have often been cited as a challenge for provision of substance use disorder treatment (37). Challenges and limitations with accessing substance use disorder treatment through telehealth, such as reduced flexibility and care coordination, also surfaced in the literature, as did logistical issues regarding connectivity and Internet accessibility (37, 38). The need for substance use disorder services also created a strain on staff. Although staff members missed work because of quarantining requirements at four out of five NHSC sites (81%, N=1,300 of 1,608), 29% (N=1,075 of 3,757) of NHSC clinicians reported working longer hours.

The interviewees commented on the longer hours required to meet patient needs and to provide additional COVID-19–related services, but they also expressed their motivation and commitment to ensuring that their community members struggling with substance use disorder were being served. Site administrators described the many ways they shifted workflows, schedules, and logistical arrangements to ensure that therapies and counseling could be provided safely.

Discussion

By serving vulnerable communities and communities with limited access to health care, NHSC clinicians play a valuable role in addressing social inequality and responding to future public health emergencies. The NHSC LRP expansion has enabled more health care workers trained in behavioral health, including in substance use disorder treatment, to work in underserved communities. This program is critical because HRSA’s National Center for Health Workforce Analysis has predicted a 23% shortfall in the number of needed psychiatrists in 2023 and a shortage of primary care providers ranging between 23% and 49%, depending on the provider’s specialty (39). We note that the findings above regarding the expansion of services cannot be attributed solely to the three NHSC LRPs discussed here (i.e., the standard LRP, Substance Use Disorder LRP, and Rural Community LRP). Several other HRSA-funded initiatives that sought to expand behavioral health services, such as the Rural Communities Opioid Response Program, the Expanding Access to Quality Substance Use Disorder and Mental Health Services grant program, and the Integrated Behavioral Health Services supplemental funding program, were implemented in communities across the country during the study period. Collectively, these efforts, the study of their impact, and sustained resources will enable HRSA to facilitate increased access to behavioral health care.

Several factors that have brought about increased demand for and access to services have also contributed to these shortages, particularly in rural and other underserved areas. These factors include increased attention to the behavioral health care needs of transition-age youths, changes in treatment-oriented care within the criminal legal system, expansions in Medicaid coverage that enable more people to seek care that they otherwise may have forgone, and the return of veterans who have behavioral health care needs. As the nation seeks to ensure access to treatment, it is also important to track the supply of trained personnel.

A key goal of the NHSC LRPs is to increase the recruitment and retention of clinicians, particularly in areas that have experienced persistent health workforce shortages. Recruiting NHSC clinicians may also be a cost-effective approach to improving the supply of behavioral health personnel, particularly in rural areas. Prior work has shown that an additional NHSC behavioral health clinician at a community health center was associated with a $3.55 reduction in cost per behavioral health care visit and a nearly $8 reduction in cost per behavioral health care visit at rural health centers. In contrast, having additional non-NHSC behavioral health staff was not associated with a cost reduction, and non-NHSC primary care clinicians contributed to an increase of $0.66 in medical care costs per visit (40). A similar study conducted by the same author group found that the presence of NHSC staff contributed to an increase in non-NHSC mental health care staff (a gain of 0.72 FTE) and NHSC behavioral health care workers (41). NHSC clinicians also showed higher productivity for substance use disorder services compared with non-NHSC staff, particularly in rural areas (42). Understanding the factors that affect the retention of NHSC clinicians can inform future efforts to sustain the health care workforce in areas that have historically experienced shortages. About three-quarters of NHSC substance use disorder site administrators (N=403 of 531, 76%) reported that the NHSC substance use disorder designation helped attract qualified clinicians. Furthermore, approximately half of all NHSC site administrators (N=787 of 1,548, 51%) reported that the presence of an NHSC clinician at their site improved the retention of other staff members and health care professionals.

Retaining skilled health professionals in rural and underserved areas is challenging because these providers may face more strains compared with their counterparts serving in urban or suburban areas, such as lower compensation and difficulty finding staffing support for case management (43). Primary care providers in rural areas may also have limited availability of specialists for referrals. Those working in underserved areas may provide care to a patient population that is often older, poorer, more likely to be uninsured, and experiencing worse health status than other patient populations. For example, in our study, clinicians in the Rural Community LRP reported that they were significantly more likely to express difficulties maintaining work-life balance, compared with clinicians in the standard LRP (59%, N=99 of 168, vs. 48%, N=1,238 of 2,579, respectively), and were significantly more likely to cite a lack of housing, recreation, and transportation as challenges (43%, N=72 of 168, vs. 33%, N=851 of 2,579, respectively).

The COVID-19 pandemic has also strained frontline health care professionals in both rural and nonrural areas across the country (44). A survey of NHSC clinicians in 20 states in winter 2020 found that about three-quarters (N=1,448 of 1,890, 77%) of NHSC clinicians were at risk for mental distress (45). A national survey of health care professionals conducted in summer 2020 found that physician addiction specialists had 1.9 greater odds of experiencing difficulty in work-life balance compared with those without addiction board certification and that physicians who worked in multiple settings or experienced staffing-related challenges were more likely to face work-life difficulties compared with peers without these stressors (46). These characteristics are common among NHSC clinicians. Another national survey of health care workers conducted between July 1 and December 31, 2020, found that 47.9% (N=4,438 of 9,266) of physicians and 63% (N=1,451 of 2,301) of nurses experienced burnout (47); a smaller but more recent survey of primary care clinicians conducted from February to March 2022 found that 62% (N=525 of 847) of clinicians knew of peers who retired early or quit during the pandemic (48).

Conclusions

This study’s findings indicate that the NHSC LRP expansion is a valuable resource for providing behavioral health care in underserved areas, particularly for substance use disorder treatment, thereby fulfilling HRSA’s goal to meet communities’ health workforce needs. In addition, the NHSC program is instrumental in advancing health equity by serving vulnerable populations in areas where there is a critical need for mental health services. It is also important to understand the facilitators and barriers that contribute to retention of NHSC providers in order to guide HRSA and NHSC sites’ efforts to sustain the health workforce capacity that has been enhanced in underserved areas. Additional studies building on these findings are needed to understand NHSC clinicians’ motivations for participating in the NHSC LRPs and how the experiences during their service contribute to their decision to continue to work in underserved areas after completing their service.